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Diabetes and incontinence

It is widely recognised globally that there is a link between diabetes and incontinence. Indications suggest that it is mostly prevalent in those with Type 2 Diabetes and most likely due to weight issues and poor glucose management (1) which may lead to deterioration of nerves and muscle health.

Studies have found that women with diabetes have up to a 70% greater risk of developing urinary incontinence than women without diabetes.(2) A research study in Norway in 2011 examined the influence of diabetes on incontinence within a group of 21,000 women; 39% of women with diabetes had incontinence and most had urge incontinence or mixed incontinence compared to 26% in women without diabetes.(3)
 
Approximately 1.7 million Australians have diabetes and 85% have type 2 diabetes (4); 200,000 New Zealanders have Type 2 Diabetes (5); 280 Australians develop diabetes every day which is one person every five minutes (4); With more than 100,000 Australians developing diabetes each year, (2016) (4) it is the fastest growing chronic condition in Australia and is increasing at a faster rate than heart disease or cancer.(6) 

Quality of life

Incontinence can have a significant impact on the quality of life for those affected. The freedom of being continent is often taken for granted. Those with incontinence face many challenges related to going out, exercise, concerns about the location of toilets and dealing with accidents. Assisting those affected to prevent, improve or manage their incontinence will have a great impact on their quality of life.

Below, we discuss how diabetes can contribute to incontinence and what you as a Healthcare Professional can look for to identify the risks and how you can assist your clients.

How TENA can help

Wearing a continence product whilst exercising can help with dryness and security and can increase your client’s confidence and the desire to keep exercising. This can be a short-term situation while pelvic floor control is regained. TENA has a wide range of sizes and styles to assist those with varying levels of incontinence including a bariatric range, pull up pants and pads and liners for light leakage – the correct pad and a good fit ensures comfort and protection. 

How is diabetes linked with incontinence

There are several factors that can either cause incontinence in a person with diabetes or can exacerbate an already existing issue. Below are some of the issues and ways that you, as a Healthcare Professional can inform and guide your clients. Incontinence may be difficult for a client to discuss, so we have listed signs to look for that could indicate incontinence is holding your client back.

Obesity

If a person with diabetes is overweight or obese it will put increased pressure on the bladder which may result in urinary frequency or urge incontinence. Excess weight also puts a strain on pelvic floor muscles, weakening them over time.

What to look for:

  • Going to the toilet more than 8 times a day.
  • Needing to get up overnight frequently to void (nocturia).
  • Rushing to the toilet for fear of having an accident.
  • Smell of urine due to leakage onto clothing, into footwear, onto furniture.
  • Showering more often due to accidents.
  • Clothes or underwear changed several times in a day.
  • Reluctance or rejection of drinking water/fluids due to fear of frequent toilet visits.
  • Reluctance to go out or go on long trips due to the fear of needing to go to the toilet.
  • Proneness for constipation – If clients are constipated there could be faecal mass pushing on the bladder causing irritation and reduction in capacity.
  • Reluctance or avoidance of exercise due to leakage. 

What to do:

  • Discuss how weight loss could have an impact on incontinence as well as their diabetes and other health issues.
  • A healthy diet can promote weight loss.
  • Encourage and discuss various types of exercise to aid with weight loss.
  • Discuss pelvic floor exercises to reduce incontinence (pelvic floor exercises) Refer your client to a trained continence physiotherapist if needed.
  • Discuss drinking well (1.5 – 2/l day) to avoid dehydration and improve bladder capacity and reduce urine concentration which can irritate the bladder
  • Encourage your client to avoid bladder irritants such as tea, coffee, alcohol and fizzy drinks
  • Suggest a continence pad to use when exercising if they have leakage. Product samples can be obtained here 
  • Educate your clients to try to hold on a bit longer when they feel the need to void to avoid a poor bladder capacity. Refer to a continence advisor for bladder retraining if needed.
  • Dietary fibre may also assist if client is prone to constipation

Nerve damange

It is known that poorly managed or long term diabetes may cause damage to nerves, mostly expressed as peripheral neuropathy (usually in the feet).  About 60% of people with diabetes have some form of nerve damage.  A neurogenic bladder is a form of diabetic neuropathy in which selective damage leads to autonomic neuropathy where the nerves affected result in decreased urination frequency(7).  This requires a specialist urological assessment and should be referred to a GP.

What to look for:

  • Frequency and urgency of urination.
  • Reduced sensation of urination, may result in incontinence.
  • Straining to void or open bowels.
  • Incomplete emptying of bladder or bowels.
  • Signs of chronic constipation or faecal impaction.
  • Urine is concentrated as bladder not emptied regularly or properly.
  • Urine may be pungent if a Urinary Tract Infection (UTI) is present due to incomplete bladder emptying.

What to do:

  • Educate your client in ways to achieve stable Blood Glucose Levels (BGL) to reduce risk of nerve damage – refer to a GP if nerve damage is already evident.
  • Advise your client to allow time for proper emptying of the bladder to avoid residual urine – best practice is to sit fully (even Men), relax and lean forward with elbows on knees, and feet supported on the floor or a small stool (8).  If there are difficulties in emptying the bladder and this technique is not helping, refer to a GP.
  • Monitor for signs of urinary retention or UTI (more commonly seen in those with low immunity and older people). There may be few, vague or no direct indications of an ongoing UTI.
  • If client is experiencing chronic constipation or faecal impaction discuss ways to add fibre into their diet and the need for good hydration.
  • Discuss wearing an incontinence pad to assist with social continence and quality of life.

Medications

All diabetes medications aim to lower blood glucose levels and some may result in increased urine output and urge incontinence. Others may cause diarrhoea and may cause faecal incontinence. Some including insulin may also cause weight gain.

Other Medications

  • Diuretics may cause urinary frequency or urge incontinence
  • Some antibiotics used to treat a UTI could cause diarrhoea resulting in faecal incontinence

What to look for:

  • Increase in need to void.
  • Urgency to void.
  • Complaints of diarrhoea.
  • Weight gain that is not diet related.

What to do:

  • Discuss possible side effects related to certain medications with GPs and educate clients.
  • Advise client if side effects do not resolve or worsen to discuss with GP.
  • Dietary modifications may help manage diarrhoea if the diabetes medication is unchangeable. Adding insoluble fibre can firm up stools. Try foods including - oats, barley, rye, fruit or vegetables.
  • Advise client - there are also medications to treat the diarrhoea.
  • Diarrhoea related to antibiotics usually resolves once treatment has ceased. If symptom is severe client may need to consult GP.
  • To help manage incontinence TENA has a wide variety of pads to suit the individual to maintain comfort, hygiene and quality of life.

Reduced immunity

The incidence of infections is increased in those with diabetes mellitus (9) High blood sugar levels can weaken the immune system as a hyperglycaemic environment can enhance the virulence of certain microorganisms (9) which may increase the risk of developing a UTI. This may exacerbate pre-existing incontinence or may cause urge incontinence.

What to look for:

  • Bladder irritability or urge incontinence.
  • Signs of infection - fever, chills, feeling hot, sweating, changes to skin integrity, cough.
  • Signs of confusion, impaired cognition, or malaise in the elderly could indicate a UTI.
  • Signs of a UTI - pungent urine, increased frequency of urination, dysuria, haematuria.

What to do:

  • Educate client in ways to maintain stable blood sugar management to lessen their risk of infection and incontinence.
  • Monitor for signs of infection and educate the client how to recognise them.
  • Educate about good perineal hygiene to avoid skin breakdowns and the risk of an ascending infection into the bladder/kidneys. Urine leakage that is left unattended can increase bacteria on the skin which could increase the risk of a UTI.
  • People with diabetes are also more prone to yeast infections. (9) Good perineal care may help avoid vaginal thrush – recommend avoiding spermicides and douches. Eating foods with active cultures such as yoghurts, fermented foods, kimchi could be recommended.
  • Consider recommending TENA incontinence products to assist with dealing with leakage whilst management regimes are being put in place.

TENA Products

TENA Diabetes Products

References

1.     https://www.incontinence.co.uk/diabetes-and-incontinence
2.     https://www.diabetesselfmanagement.com/managing-diabetes/.../urinary-incontinence/
3.      Diabetes and urinary incontinence- prevalence data from Norway, M.Ebbesen,Y.Hannestad,K.Midthjell, S.Hunskaar, Acta Obstetrica et Gynecologica  2007; 86: 1256-1262
4.     https://www.aihw.gov.au/reports-statistics/health-conditions
5.      https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/diabetes
6.      https://www.diabetesaustralia.com.au/
7.     https://www.diabetes.co.uk/diabetes-complications/neurogenic-bladder.html
8.     https://www.bladderandbowel.org/help-information/resources/toilet-positions/
9.     https://www.verywell.com/what-are-the-common-infections-with-diabetes-1087622